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Monday, July 25, 2011

Evaluating the Communications Skills of Potential Medical Students: Looking at the "Whole Person"

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As US medicine is becoming increasingly seen as more impersonal and technological, there is an unsurprising reaction among the people it serves. While Americans unquestionably value the benefits of high-tech interventions (at least for themselves and their loved ones – maybe not so much for others), they also want doctors who will listen to them, understand them and care about them. There is a definite sense that technical skill is great but the decision about how and to whom to apply that skill requires understanding the person, not just the disease and the potential intervention.

Most people are not in a good position to evaluate physician skill on a technical basis. Most studies on this topic have found that in general people assume quality – they assume the knowledge and skill of their doctors, and of the hospitals in which they practice. This is why hospitals and practices often compete on the basis of “hotel” services -- is there a nice lobby, is the place modern and impressive, are the rooms big, is the food good -- as well as issues such as “are complaints addressed”. When people are unhappy with their medical provider, doctor or hospital or other, it is usually because they had a bad outcome or because they didn’t get the “service” that they wanted. All of us can relate to that, but these are not always the result of “bad medicine” being practiced. Not getting the service you wanted may be medically appropriate if that service was not indicated or even potentially harmful. The bad outcome may be because the provider didn’t do a good job, but it could just as well be because there was inherent risk in both the procedure done and the underlying disease that it was intended to treat. Indeed, it may be that the potential benefits of the procedure were oversold and the risks minimized; when people are suffering they are often likely to look at potential benefits and not so much at risk. It is therefore the job of the provider to make clear what the benefits are most likely to be (not just “best case scenario”). A cure? How often? An improvement? How much? A longer life? How long? And in what condition? And what are the risks? And costs? This, of course, gets back to communication.

On the whole, medical students have not been selected for communication skills. Sure, admissions committees value them, but they are not “make or break” the way test scores are. Most medical school faculty have a variation on the (true) story I heard from a colleague; the interviewer, a high tech physician, wrote on the applicant’s interview form “Great scores, zero interpersonal skills. Admit.” Unfortunately for the applicant, arguably more fortunately for his/her future patients, those interpersonal skills were so poor s/he finally failed out when s/he moved from the test-taking years to the actual patient care years.

A new medical school in Roanoke, VA, the Virginia Tech Carrilion School of Medicine, is formally integrating assessments of communication skills into its admissions process, as described in the NY Times July 11, 2011, New for Aspiring Doctors, the People Skills Test. The particular method that they are using is the “Multiple Mini-Interview”, or MMI, in which applicants have a series of 8-minute discussions with an interviewer who presents them with a problem – an ethical issue, a values conflict, a team dynamic – and looks for how well the interviewee is able to approach the problem, to think about, and to express their concerns. There is no “right answer”; “Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams.” This is not the traditional model for selecting doctors, who are classically opinionated, the “boss”, and so sure of themselves as to often be accurately characterized as arrogant. The article indicates that many other medical schools are looking at this system, originally developed at McMaster University in Ontario, Canada, or another similar one.

Of course, there was a response to this article and not all of it was positive. Most of the letters published in the Times on July 18 were critical in one way or another. Several were from physicians, but I will not mention the specialty for fear of feeding stereotyping (if you are interested in knowing, following the link above). While one writer set up a straw man to attack: “Charm won’t save a patient’s life,” which confuses (presumably on purpose) the ability to communicate and work with others as “charm”, other letters suggested that their authors had familiarity with the specific test, the MMI. They perceived flaws in the test, suggesting that it might overselect extraverts compared with introverts and be disadvantageous for the applicant “…with less ‘real world’ experience or an applicant with fewer resources who may have less experience navigating ethical discussions,” or that it “may ‘weed out’ talented applicants who have the compassion and capacity for great “people skills” but have not had the time or opportunity to nurture them.” Another worried “that the stressful mini interviews might screen out not bullies, but mildly awkward people who would be fine when dealing with real patients and nurses.”

Another writer was generally supportive, but worried that “…while speed ethics tests are at best an intriguing experiment, at worst they are the latest gimmick”. This person suggested that “Medical schools might try looking at the whole person.” Of course, “looking at the whole person” is exactly what Virginia Tech Carilion and other medical schools are trying to do, whether using the MMI or other methods of assessment. They are trying to get instruments to measure that “whole person” beyond the ability to score well on multiple-choice tests, which have, after all, long been the cornerstone for deciding who gets into medical school. Our “charm” writer suggests that the answer is to “select brilliant students, and then cultivate their social skills.” Of course, all the data suggests that “brilliance” aside, it is much easier to teach knowledge and technical skill (the whole point of the medical education experience) than it is to teach social skill, as demonstrated by the elegant work of Dr. Robert Sade and colleagues, “Criteria for the Selection of Medical Students”[1], published in the Annals of Surgery in 1985.

Much other research has demonstrated that the traditional methods of selection (high test scorers, mostly from privileged backgrounds) predict success in the first two years of test-based education but not at all in the clinical years or in practice. MMI also has a research basis; Dr. Harold Reiter, the McMaster professor who developed it says “…candidate scores on multiple mini interviews have proved highly predictive of scores on medical licensing exams three to five years later that test doctors’ decision-making, patient interactions and cultural competency.”

Perhaps the MMI is not the best tool for assessing communication and teamwork skills, but it is a good one, and those are important skills. Those skills, as Dr.Sade identified, are among those we should be selecting for. If the applicant has “less ‘real world’ experience” but has “…not had the time or opportunity to nurture them,” maybe it is important for them to do that and find out if they are capable before they are accepted to medical school.

The correlations we will ultimately need to have to see if our methods of medical student selection are good or not will not be with performance on multiple choice tests. They will look longer term at specialty choice, practice location and at the benefit to the health of the patients they care for. Most important will be the overall health of our population. In the meantime, we should at least accept medical students who have the basic interpersonal skills to communicate effectively with another human being.